Dear Mrs Lake Sarah Nadine Louise GIBBS I write to formally respond to the Regulation 28: Report to Prevent Future Deaths issued following this inquest in October 2020. I apologise on behalf of the Trust for the delay: no disrespect was intended. I understand that (Trust Solicitor) has already written to your team to explain how this occurred. It is now my intention to provide you with the information that was originally collated and to update you with regards to the position now. During the inquest, a concern was raised "with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over. Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood for errors in communication information. It was not known whether this tool is in use although it was "hoped" it is being used." December 2020 SBARD is a structured form of communication that consists of standardised prompt questions in four sections: S (Situation); 8 (Background); A (Assessment) and R (Recommendation). It can also include a final section, D (Decision). As at December 2020, staff were encouraged and trained to use SBARD as a communication method across the hospital. In some areas, there were posters displaying how the tool benefits communication and what the tool is with the steps clearly laid out. These were first issued by the Critical Care Outreach Team. SBARD was consistently used for the presentation of cases to SIG and providing information in response to enquiries for the CQC. There was not the evidence

available to provide assurance that this communication tool was in consistent and regular use with patient facing teams for escalating concerns. The Trust was also planning to undertake a large scale digital improvement project to implement eObs and a clinical messaging system to improve the escalation of deteriorating patients to response teams. In addition, we were planning to expand the Recognise and Respond team with their remit to include training and education. December 2022 SBARD is integrated into the patient handover used by the wards at every handover. There is a template document used with each section of the SBAR tool to be completed by staff. This has been in place at the Trust for approximately 18 months. EObs has been introduced at the Trust. Since June 2021, the Recognise and Response Team (RRT) has been expanded to provide their services 24/7. The RRT works across inpatient wards responding to acutely deteriorating patients, attending resuscitation calls in the hospital as well as delivering education, training and quality improvement projects. The RRT lead in the education and training of Trust staff in the assessment and management of acutely unwell patients, providing basic, intermediate and advanced resuscitation courses and bespoke acute deteriorating patient courses for medical students, doctors, nurses, midwives and HCAs. The RRT teach SBARD on all new staff inductions; Assess, Communicate, Treat Courses; ALERT course; HCA study day; and BEACH course, as well as ad hoc ward training. The t eam are about to launch a new NEWS2 e-learning course which also teaches SBARD. I hope the information provided within this letter reassures you about the steps taken to implement SBARD into our processes and to improve communication between teams.